ENS 43766
ENS Event | |
|---|---|
13:30 Oct 10, 2007 | |
| Title | Missing I-131 Gel Capsule |
| Event Description | To assist the Hot Lab Tech, at 9:20 AM on October 10, 2007, another Nuclear Medicine Technologist placed a gel capsule containing 55 microCuries of I-131 into a Leucite thyroid neck phantom and oriented the phantom for an anterior projection to calibrate the thyroid uptake counting system for dosimetry measurements needed on a thyroid treatment patient . After setting the counter for a ten-minute count she informed the Hot Lab Tech that the sample was counting. She did not stay with the thyroid neck phantom and counting system which was located in an alcove approximately twenty feet from the door to the Hot Lab. While the neck phantom was visible from the doorway of the Hot Lab, the Hot Lab Tech did not have it under constant observation. However, there were Nuclear Medicine personnel in the corridor between the Hot Lab and this alcove almost continuously during the counting procedure.
At 9:38 AM, the Hot Lab Tech oriented the neck phantom for a posterior projection and set the system for a second ten-minute count. When the Hot Lab Tech returned to the Thyroid counter at 10:15 AM, she discovered that only background counts had been recorded for the ten-minute counting period. A check of the neck phantom revealed that it contained no radioiodine capsule. After an extensive but unsuccessful search by Nuclear Medicine personnel, Health Physics was called for assistance at 11:30 AM. A Health Physics team spent several hours searching all conceivable areas but, no capsule was found. Security was notified along with the local police. The local police responded, took fingerprints but, as of yet, have not responded further. A review of the DVD from the security camera located outside the Hot Lab and Injections rooms failed to determine the fate of the radioiodine capsule but did confirm that there were Nuclear Medicine personnel in sight of the neck phantom for essentially the entire procedure and especially for the 18 minute window (from the end of the first count to the beginning of the second count) when the capsule went missing. An investigative Committee was formed to query all Nuclear Medicine Technical personnel and Nuclear Medicine nurses and to determine the fate of the lost capsule and/or the root cause of the event. This committee was chaired by the Radiation Safety Officer and included the Assistant Manager of Radiology, the Chief of Nuclear Medicine, the Operations Director for Radiology, the Associate RSO and the Director of Human Resources. The investigation failed to determine the fate of the missing radioiodine capsule. The investigation revealed that the Chief Technologist had approved the calibration of the thyroid uptake counting system in the alcove rather than a locked room because he considered the capsule in the neck phantom to constitute 'secure.' The investigation revealed some attitude problems on the part of the technical staff and some deviations from required 'good radiation safety practices' unrelated to the missing capsule. Corrective actions implemented include: 1. Dismissal of the Chief technologist. 2. Dismissal of the Hot Lab technologist responsible for the calibration of the thyroid uptake counting system. 3. Year long probation for all remaining Nuclear Medicine Technologists. 4. Increased training sessions for all Nuclear Medicine technologists. 5. Relocation of the office of the Assistant Manager of Radiology to the Nuclear Medicine area. 6. Additional security cameras ordered for other areas of Nuclear Medicine. 7. Random review of recordings from security cameras by Health Physics to verify adherence to good radiation safety practices. 8. Changes to the door locks to severely restrict traffic flow in and access to the Nuclear Medicine areas. 9. Increase observation of Nuclear Medicine activities by Health Physics. 10. Increased observation of Nuclear Medicine activities by physicians and residents. 11. Relocation of the Thyroid uptake counting system to a room that can be locked when no-one is in attendance during a calibration procedure. 12. Requiring that sources being used outside of the Hot Lab will be under the control and responsibility of a single individual for the entire time that the source is out of the Hot Lab. This incident has been thoroughly reviewed with our Radiation Safety Committee and our Subcommittee on Human Use of Radioisotopes. The licensee will continue to search for the missing source and will continue close scrutiny of all Nuclear Medicine operations. As of this date, the fate of the capsule is still unknown. The current activity, due to decay, would be approximately 8 microcuries. The licensee notified NRC Region I (Pam Henderson), Dairy Township Police Department, and Director, PA Bureau of Radiation Protection. THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. |
| Where | |
|---|---|
| Penn State Hershey Medical Center Hershey, Pennsylvania (NRC Region 1) | |
| License number: | 37-13831-01 |
| Organization: | Penn State Hershey Medical Center |
| Reporting | |
| 10 CFR 20.2201(a)(1)(ii) | |
| Time - Person (Reporting Time:+551.72 h22.988 days <br />3.284 weeks <br />0.756 months <br />) | |
| Opened: | Kenneth L. Miller 13:13 Nov 2, 2007 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Nov 2, 2007 |
| 43766 - NRC Website | |
Penn State Hershey Medical Center with 10 CFR 20.2201(a)(1)(ii) | |
WEEKMONTHYEARENS 437662007-10-10T13:30:00010 October 2007 13:30:00
[Table view]10 CFR 20.2201(a)(1)(ii) Missing I-131 Gel Capsule 2007-10-10T13:30:00 | |